Concurrent Hospice and Dialysis: Proof of Concept
Authors: Catherine R. Butler, Melissa W. Wachterman, Ann M. O’Hare
Journal: Journal of the American Society of Nephrology (2022)

Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has. —Margaret Mead Among Americans receiving dialysis for kidney failure, rates of hospice use are much lower and hospice stays much shorter than for other populations.1,2 As the dominant payer for both dialysis and hospice care in the United States, Medicare program eligibility criteria and payment policies have had an outsized impact on how both of these services are delivered. Because Medicare hospice beneficiaries with a primary hospice diagnosis of kidney failure are not eligible to receive dialysis under the Medicare ESKD entitlement, concurrent receipt of hospice and dialysis services is rare in the United States and largely restricted to those with a primary hospice diagnosis other than kidney failure. In this issue of JASN, Ernecoff et al.3 describe their work to develop a novel concurrent care program that allowed patients with a hospice diagnosis of kidney failure to receive a limited number of palliative dialysis treatments after hospice enrollment. The program was supported by a local partnership between the Dialysis Clinic, Inc.'s Real Engagement Allowing Complete Health Program (DCI-REACH) and the University of Pittsburgh Medical Center (UPMC) Family Hospice in western Pennsylvania. For patients receiving the Medicare Hospice Benefit (MHB), UPMC Family Hospice negotiated a contract with DCI-REACH to pay for up to ten hemodialysis sessions or a month of peritoneal dialysis. Eligible patients included those receiving dialysis at a DCI-REACH clinic who were expected to live less than 2 months on dialysis and whose goals were aligned with receiving a limited amount of dialysis after hospice enrollment. During the first 3 years, the program enrolled a total of 43 patients with a mean age of 74 (SD 11) years, including 72% with congestive heart failure, 42% with chronic lung disease, 35% with diabetes, and 28% with dementia. After enrolling in the program, 23 patients did not receive any dialysis treatments, 15 received an average of 3.5 (range, 1–9) sessions of hemodialysis, and five received an average of 19 (3–65) days of peritoneal dialysis. The median hospice length of stay was 9 (range, 1–76) days for all participants, 13 (4–76) days for those who received dialysis, and 6 (1–17) days for those who did not. During follow-up, only two patients were hospitalized, 28 died at home, ten died in an inpatient hospice, five died in a skilled nursing facility, and none died in the hospital. Although the study did not include a comparison group, very low rates of hospital admission, more time spent in hospice compared with the overall dialysis population, and an absence of in-hospital deaths suggest that the program probably did shape the care that program enrollees received at the end of life. Planned qualitative analyses to understand the perspectives and experiences of key stakeholders will be important in gauging the value of the program, guiding program improvement, and building community and legislative support for concurrent care. The Medicare ESKD entitlement—which was signed into law in 1972 amid backlash against the early experience of rationing dialysis in the United States—included few restrictions on eligibility.4 In contrast, entry criteria for the the MHB—which was established in 1982 with the goal of providing a cost-effective alternative to usual care primarly for Medicare beneficiaries dying from cancer—were extremely restrictive.5 Over time, the ESKD program has grown beyond all expectations and now caters to a large number of medically complex and debilitated older adults,6 many of whom could benefit from hospice services as they approach the end of life. However, rigid and outdated hospice eligibility criteria grounded in an artificial dichotomy between curative and palliative care mean that most patients undergoing dialysis never receive hospice services or enroll only when they are ready to stop, or too sick to continue, dialysis treatments.7 The novel concurrent care program developed by Ernecoff et al.3 and their organizational partners demonstrates a strong commitment to a patient- and family-centered vision of end-of-life care for patients with kidney failure. Because limited funds were available to support the program, there had to be restrictions on how much dialysis could be provided after hospice enrollment. To ensure that patients' goals aligned with what the program could offer, only patients with an estimated prognosis of less than 2 months on dialysis who wished to continue their dialysis treatments for a limited time after hospice enrollment were eligible to participate. Fortunately, program costs were modest, and none of the participants reached the maximum allowable number of treatments. However, efforts to expand the program to include a broader hospice-eligible population (e.g., life expectancy less than 6 months) would probably require a more permissive approach to the provision of dialysis after hospice enrollment, especially given the challenges of prognostication among members of this population.8 As the authors mention, the feasibility of providing concurrent dialysis and hospice care is currently being evaluated under several value-based purchasing models. The Centers for Medicare and Medicaid Services (CMS), which pays not only for dialysis and hospice services, but also for emergency and acute care for Medicare beneficiaries, is ideally positioned to explore the feasibility of concurrent care on a larger scale. Value-based approaches to the provision of concurrent care will hopefully consider not just the cost of providing dialysis and hospice services but also potential cost savings related to the lower use of acute care services near the end of life. Such cost savings could be substantial given the very intensive patterns of end-of-life care observed in the Medicare dialysis population.9,10 Because CMS has access to opportunities for cost shifting that were not available to DCI-REACH and UPMC Family Hospice in crafting their program, value-based models could hopefully support a more liberal approach to program enrollment, with fewer (or no) restrictions on the amount of dialysis permitted after hospice entry. The concurrent care program developed by Ernecoff et al.3 offers a compelling proof of concept. We hope that this work will inspire and guide current and future efforts to improve access to hospice services and support a more patient- and family-centered approach to end-of-life care for members of the dialysis population. Disclosures A.M. O'Hare receives grant support from NIDDK and VA HSR&D. In the last 36 months, she has received financial support for honoraria and travel from the American Society of Nephrology, Devenir Foundation, and Hammersmith Hospital. She serves on the editorial board for JASN. A.M.O'Hare reports patents or royalties: partner receives financial compensation for his work for ABIM; and advisory or leadership role: member of the editorial board for JAMA Internal Medicine, JASN, CJASN, AJKD, and the Canadian Journal for Kidney Disease, and husband is a member of the ABIM. All remaining authors have nothing to disclose. Funding C.R. Butler was supported by K23DK129777 and M.W. Wachterman was supported by K23AG049088.